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CASE REPORT Beta-blocker stress echocardiography in an aortic stenosis patient with associated left ventricular outflow tract obstruction Masataka Sugahara Akiko Goda Mitsuru Masaki Ayumi Nakabo Shohei Fujiwara Miho Fukui Kanako Itohara Shinichi Hirotan Kazuo Komamura Masaaki Kawabata-Lee Takeshi Tsujino Tohru Masuyama Received: 11 December 2013 / Revised: 17 March 2014 / Accepted: 31 March 2014 / Published online: 16 April 2014 Ó Japanese Society of Echocardiography 2014 Abstract An 80-year-old man visited our hospital because of dyspnea on exertion from 6 months ago. Echo Doppler study showed severe calcification in the aortic valve with restricted movement and the sigmoid septum causing obstruction at the LV outflow tract (LVOT). Considering the aortic valve area (AVA) might have been inaccurately estimated, we carried out beta-blocker stress echocardiography. The transaortic pressure gradient and AVA were respectively calculated as 52 mmHg and 0.90 cm 2 before propranolol administration and as 64 mmHg and 0.86 cm 2 after propranolol administration. Thus, beta- blocker stress echocardiography may provide an accurate assessment of AS if the LVOT obstruction is concomitant. Keywords Aortic stenosis Á Sigmoid septum Á Echo Doppler Á Beta-blocker Á Stress echocardiography Case report The patient was an 80-year-old man who visited our hos- pital because of dyspnea on exertion from 6 months ago. He was 167 cm tall and 53 kg (BSA = 1.59 m 2 ). His blood pressure was 138/70 mmHg. Echo Doppler study showed LV hypertrophy with chamber dilatation and left atrial dilatation. The LV ejection fraction was 66 %. The aortic valves (AV) had severe calcification, and their movement was restricted. There was a sigmoid septum at the LV outflow tract (LVOT) with systolic anterior motion of the mitral anterior leaflet. Continuous-wave Doppler LVOT flow velocity was 2.5 m/s, and trans-aortic valve flow velocity (V AV ) was 4.4 m/s (Fig. 1). Because there was an accelerated flow at LVOT due to dynamic subaortic obstruction, the pressure gradient of the aortic valve (DP AV ) was estimated using the simplified Bernouli equation: DP AV = 49(V AV ) 2 - 49(V LVOT ) 2 (mmHg), where V LVOT stands for velocity at the LVOT. It was 52 mmHg, and the continuity equation-based aortic valve area (AVA) was 0.90 cm 2 . Considering AVA might be inaccurately estimated because of the associated dynamic subaortic obstruction, we carried out drug stress echocar- diography. Specifically, 2 mg propranolol was intrave- nously administered to attenuate the subaortic stenosis. The V LVOT and V AV decreased from 2.5 to 1.3 m/s and from 4.4 to 4.2 m/s, respectively, after intravenous injection of propranolol. The DP AV and AVA were respectively cal- culated as 52 mmHg and 0.90 cm 2 before propranolol administration and as 64 mmHg and 0.86 cm 2 after pro- pranolol administration (Fig. 2). Because we diagnosed the AS as severe, the patient underwent aortic valve replace- ment in a month. Discussion The number of elderly patients with degenerative AS has been markedly increasing, and the value of echocardiog- raphy as a standard technique for the assessment of AS is particularly important in these patients [1]. The sigmoid septum is frequently associated with AS in elderly patients M. Sugahara Á A. Goda Á M. Masaki Á A. Nakabo Á S. Fujiwara Á M. Fukui Á K. Itohara Á S. Hirotan Á K. Komamura Á M. Kawabata-Lee Á T. Masuyama (&) Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan e-mail: [email protected] T. Tsujino Department of Pharmacy, School of Pharmacy, Hyogo University of Health Science, Kobe, Japan 123 J Echocardiogr (2014) 12:68–70 DOI 10.1007/s12574-014-0212-6

Beta-blocker stress echocardiography in an aortic stenosis patient with associated left ventricular outflow tract obstruction

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Page 1: Beta-blocker stress echocardiography in an aortic stenosis patient with associated left ventricular outflow tract obstruction

CASE REPORT

Beta-blocker stress echocardiography in an aortic stenosis patientwith associated left ventricular outflow tract obstruction

Masataka Sugahara • Akiko Goda • Mitsuru Masaki • Ayumi Nakabo •

Shohei Fujiwara • Miho Fukui • Kanako Itohara • Shinichi Hirotan •

Kazuo Komamura • Masaaki Kawabata-Lee • Takeshi Tsujino • Tohru Masuyama

Received: 11 December 2013 / Revised: 17 March 2014 / Accepted: 31 March 2014 / Published online: 16 April 2014

� Japanese Society of Echocardiography 2014

Abstract An 80-year-old man visited our hospital

because of dyspnea on exertion from 6 months ago. Echo

Doppler study showed severe calcification in the aortic

valve with restricted movement and the sigmoid septum

causing obstruction at the LV outflow tract (LVOT).

Considering the aortic valve area (AVA) might have been

inaccurately estimated, we carried out beta-blocker stress

echocardiography. The transaortic pressure gradient and

AVA were respectively calculated as 52 mmHg and 0.90

cm2 before propranolol administration and as 64 mmHg

and 0.86 cm2 after propranolol administration. Thus, beta-

blocker stress echocardiography may provide an accurate

assessment of AS if the LVOT obstruction is concomitant.

Keywords Aortic stenosis � Sigmoid septum � Echo

Doppler � Beta-blocker � Stress echocardiography

Case report

The patient was an 80-year-old man who visited our hos-

pital because of dyspnea on exertion from 6 months ago.

He was 167 cm tall and 53 kg (BSA = 1.59 m2). His

blood pressure was 138/70 mmHg. Echo Doppler study

showed LV hypertrophy with chamber dilatation and left

atrial dilatation. The LV ejection fraction was 66 %. The

aortic valves (AV) had severe calcification, and their

movement was restricted. There was a sigmoid septum at

the LV outflow tract (LVOT) with systolic anterior motion

of the mitral anterior leaflet. Continuous-wave Doppler

LVOT flow velocity was 2.5 m/s, and trans-aortic valve

flow velocity (VAV) was 4.4 m/s (Fig. 1). Because there

was an accelerated flow at LVOT due to dynamic subaortic

obstruction, the pressure gradient of the aortic valve

(DPAV) was estimated using the simplified Bernouli

equation: DPAV = 49(VAV)2 - 49(VLVOT)2 (mmHg),

where VLVOT stands for velocity at the LVOT. It was

52 mmHg, and the continuity equation-based aortic valve

area (AVA) was 0.90 cm2. Considering AVA might be

inaccurately estimated because of the associated dynamic

subaortic obstruction, we carried out drug stress echocar-

diography. Specifically, 2 mg propranolol was intrave-

nously administered to attenuate the subaortic stenosis. The

VLVOT and VAV decreased from 2.5 to 1.3 m/s and from 4.4

to 4.2 m/s, respectively, after intravenous injection of

propranolol. The DPAV and AVA were respectively cal-

culated as 52 mmHg and 0.90 cm2 before propranolol

administration and as 64 mmHg and 0.86 cm2 after pro-

pranolol administration (Fig. 2). Because we diagnosed the

AS as severe, the patient underwent aortic valve replace-

ment in a month.

Discussion

The number of elderly patients with degenerative AS has

been markedly increasing, and the value of echocardiog-

raphy as a standard technique for the assessment of AS is

particularly important in these patients [1]. The sigmoid

septum is frequently associated with AS in elderly patients

M. Sugahara � A. Goda � M. Masaki � A. Nakabo �S. Fujiwara � M. Fukui � K. Itohara � S. Hirotan �K. Komamura � M. Kawabata-Lee � T. Masuyama (&)

Cardiovascular Division, Department of Internal Medicine,

Hyogo College of Medicine, Nishinomiya, Hyogo, Japan

e-mail: [email protected]

T. Tsujino

Department of Pharmacy, School of Pharmacy, Hyogo

University of Health Science, Kobe, Japan

123

J Echocardiogr (2014) 12:68–70

DOI 10.1007/s12574-014-0212-6

Page 2: Beta-blocker stress echocardiography in an aortic stenosis patient with associated left ventricular outflow tract obstruction

h VAV 4.4 m/secΔP 52mmHgAVA 0.90cm2

f

a b

c d e

g VLVOT 2.5 m/sec

Fig. 1 Echo Doppler was performed on his admission. a Two-

dimensional echocardiogram of the left side parasternal long axis

view at end-diastole. b Two-dimensional echocardiogram of the left

side parasternal long axis view at end-systole. c Two-dimensional

echocardiogram of the left side parasternal long axis view showing

LVOT at end-diastole. d Two-dimensional echocardiogram of the left

side parasternal long axis view showing LVOT at mid-systole.

e M-mode echocardiogram showing systolic anterior motion of the

mitral anterior leaflet. f Color Doppler echocardiogram showing

accelerated LVOT flow. g Pulse-wave Doppler echocardiogram and

continuous-wave Doppler echocardiogram through the LVOT. h Con-

tinuous-wave Doppler echocardiogram through the aortic valve

a c VAV 4.2 m/sec ΔP 64mmHg AVA 0.86cm2

b VLVOT 1.3m/sec

Propranolol Administration Pre Post

BP (mmHg) 149/64 145/60

HR (bpm) 52 48

VLVOT (m/sec) 2.5 1.3

VAV (m/sec) 4.4 4.2

ΔP (mmHg) 52 64

AVA (cm2) 0.90 0.86

d

BP: Blood pressure HR: Heart rate LVOT : Le� ventricular ou�low tract VLVOT: Flow velocity through the LVOT VAV: Flow velocity through the aor�c valve ΔP: Pressure gradient between the LVOT and the ascending aorta AVA: Aor�c valve area

Fig. 2 We performed

propranolol stress

echocardiography. a Two-

dimensional echocardiogram of

the left side parasternal long

axis view showing LVOT.

b Pulse-wave Doppler

echocardiogram through the

LVOT. c Continuous-wave

Doppler echocardiogram

through the aortic valve

J Echocardiogr (2014) 12:68–70 69

123

Page 3: Beta-blocker stress echocardiography in an aortic stenosis patient with associated left ventricular outflow tract obstruction

simply because of the steady increase in sigmoidity of the

ventricular septum with aging [2]. A sigmoid septum fre-

quently causes an obstruction at the LVOT because of the

sharp angle between the mid-line axis of the ascending

aorta and that of the interventricular septum [2]. If suba-

ortic stenosis is associated with aortic stenosis, it is

unpredictable whether it will cause over- or underestima-

tion of DPAV in individual patients; thus, the best way

should be to decrease the degree of subaortic stenosis as

much as possible. Therefore, we attempted to normalize

VLVOT using a negative inotropic drug (propranolol). Beta-

blockers are an established treatment for LVOT obstruction

in HCM subjects [3]. For instance, intravenous landiolol

infusion attenuated LVOT obstruction caused by the sig-

moid septum on general anesthesia [4].

Although dobutamine and/or exercise stress is a popular

intervention to improve the accuracy of AS assessment,

such a stress was obviously inappropriate in this patient.

On the contrary, intervention with a negative inotropic

agent may be useful in such patients. Thus, beta-blocker

stress echocardiography may provide accurate assessment

of AS if the LVOT obstruction is concomitant.

Conflict of interest There are no financial or other relations that

could lead to a conflict of interest.

References

1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic

assessment of valve stenosis: EAE/ASE recommendations for

clinical practice. J Am Soc Echocardiogr. 2009;22:1–23.

2. Toth AB, Engel JA, McManus AM, et al. Sigmoidity of the

ventricular septum revisited: progression in early adulthood,

predominance in men, and independence from cardiac mass. Am

J Cardiovasc Pathol. 1988;2:211–23.

3. Sherrid MV, Pearle G, Gunsburg DZ. Mechanism of benefit of

negative inotropes in obstructive hypertrophic cardiomyopathy.

Circulation. 1998;97:41–7.

4. Omae T, Tsuneyoshi I, Higashi A, et al. A short-acting beta-

blocker, landiolol, attenuates systolic anterior motion of the mitral

valve after mitral valve annuloplasty. J Anesth. 2008;22:286–9.

70 J Echocardiogr (2014) 12:68–70

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